About a Boy

Transgender surgery at sixteen.

At fourteen, Skylar, born a girl, adopted a boy’s name; at sixteen, he started taking testosterone and had a mastectomy. Not concerned with being a “macho bro,” he plans to date boys.Credit Photograph by Pari Dukovic

For high-school seniors like Skylar—who live in prosperous suburbs, have doting parents, attend good schools, and get excellent grades while studding their transcripts with extracurricular activities—the hardest part of the college application is often the personal essay. They’re typically asked to write about some life-changing experience, and, if their childhood has been blessedly free of drama, they may find themselves staring at a blank screen for a long time. This was not a problem for Skylar.

Skylar is a boy, but he was born a girl, and lived as one until the age of fourteen. Skylar would put it differently: he believes that, despite biological appearances, he was a boy all along. He’d just been burdened with a body that required medical and surgical adjustments so that it could reflect the gender he knew himself to be. At sixteen, he started getting testosterone injections every other week; just before he turned seventeen, he had a double mastectomy. The essay question for the University of Chicago, where Skylar submitted an early-action application, invited students to describe their “archnemesis (either real or imagined).” Skylar’s answer: “Pre-formed ideas of what it meant to have two X chromosomes.” No matter what people thought they saw when they looked at him, Skylar wrote, he knew that he “was nothing along the lines of a girl.”

Skylar is an F.T.M., or “female-to-male,” transgender person, a category that has been growing in visibility in recent years. In the past, females who wished to live as males rarely sought surgery, in part because they could “pass” easily enough in public; today, there is a desire for more thorough transformations. Skylar took hormones and underwent “top surgery” at a much younger age than would have been possible even a decade ago. Yet, in his new guise, he doesn’t labor to come across as conventionally masculine. Like many “trans” people of his generation, he is comfortable with some gender ambiguity, and doesn’t feel the need to be, as he puts it, a “macho bro.” He is not sure yet if he will have genital reconstruction when he’s older.

Skylar lives in an affluent, wooded town near New Haven, a liberal enclave where nobody seriously challenged his decision to change gender. Some of his peers even expressed a certain envy. As he explained in his application essay, classmates kept telling him, “This is the most fundamental essence of who you are, Skylar. You can’t possibly get through an entire college application without bringing it up. (Ironically, I haven’t.) This will be your ticket into your dream school.” It was an attitude that irritated Skylar, because, he wrote, “I’ve finally reached a point in my life where my transition is not consuming my life.”

Many trans kids have a very hard time. They are bullied at school, rejected by their families, and consigned to marginal—even desperate—lives. Teen-agers who identify as transgender appear to be at higher risk for depression and suicide. Yet Skylar’s more seamless story is becoming increasingly common. Middle-class parents today tend to actively help their children get settled on a path in life, and often subscribe to the notion that “early intervention” is best for all kinds of conditions. Many therapists have begun to speak of even very young children as transgender (a category that few clinicians of past generations would have applied to them). And plastic surgery, tattoos, and piercings have made people more comfortable with body modification. In such a context, gender surgery in late childhood may no longer seem extreme. Because this change is happening so fast, and amid a flurry of mostly positive media attention, it can be hard to recognize what a radical social experiment it is.

Transgenderism has replaced homosexuality as the newest civil-rights frontier, and trans activists have become vocal and organized. Alice Dreger, a bioethicist and historian of science at Northwestern University, says, “The availability of intervention and the outspokenness of the transgender community are causing a lot more people to see themselves as transgender, and at younger ages.” A recent survey of thirty-five hundred transgender Americans found that, the younger the respondents, the more likely they were to have had “access to transgender people and resources at a young age,” and to have identified as trans at a young age. In a follow-up survey, more than two-thirds of the respondents between the ages of eighteen and twenty-two said that they had known other transgender people before adopting the identity themselves, compared with a quarter of those fifty-three and older.

A kid today who hasn’t met other transgender young people can readily find them in popular culture and social media. Such characters appear on “Glee” (naturally) and on “DeGrassi.” On the Internet, Tumblrs and Listservs and thousands of YouTube videos chronicle the gender transitions of teen-agers. Shot on blurry Webcams in the family basement or in jumbled, poster-covered bedrooms, they variously resemble diaries, instruction manuals, music videos, and manifestos. Last spring, Warren Beatty and Annette Bening’s child Stephen—born Kathlyn—attracted attention after making a video of himself for the site We Happy Trans. Stephen, then twenty and a sophomore at Sarah Lawrence College, explained that, at fourteen, he had “transitioned socially,” adopting his new name and attending school as a boy. His monologue was smart, whimsical, and laden with jargon. “I identify as a transman, a faggy queen, a homosexual, a queer, a nerdfighter, a writer, an artist, and a guy who needs a haircut,” he said. He revealed that he was taking testosterone while “presenting in a femme way,” adding, “It’s nice to finally be able to have my identity be legible to people.”

Skylar told me that “the Internet, and the fact that there are resources readily available,” had made a big difference in his decision to change gender. “That makes it much easier for ideas to spread,” he said. “And this is just another idea to be spread.”

In elementary school, Skylar was what used to be called a tomboy. He kept his sandy hair cut short, and wore polo shirts and cargo pants. (I’ll use “he” for the younger Skylar, too. I don’t even know his former name—this was one remnant of his past that he refused to share.) In the early years of grade school, he hung out at recess with the boys who ran around playing real-life versions of video games, though he also had close friends who were girls. Waiters and sales clerks often assumed that Skylar was a boy, and it soon became clear to his parents, Melissa and Chip, that Skylar didn’t want them to correct the misimpression.

Skylar’s family was not the type to disapprove of an insufficiently feminine daughter. Chip is a trim, Yale-educated I.T. consultant; Melissa has a master’s degree in forestry and runs a nonprofit environmental organization. They divorced when Skylar was nine, and though the breakup was painful, Melissa and Chip remain aligned as parents, sharing a cheerful confidence about Skylar and his older sister, Dakota, now a sophomore at Pomona College. “Skylar never wanted to wear a dress,” Melissa said. “What did I care? I’m not going to force my kids to do things that make them unhappy. That’s the last thing I want to do. Obviously.”

Partly because of this attitude, and partly because little girls can get away with being boyish—in contrast to little boys, who still cannot easily get away with being girlish—Skylar did not have a hard time in elementary school. When I asked him about difficult moments as a kid, he thought for a minute and then mentioned a school assembly at which a magician asked for male volunteers. Skylar raised his hand and was picked. “The kids all started shouting, ‘No! That’s a girl,’ ” he recalled. Later, the school counsellor asked Skylar to stop by for a chat. “I would just get confused when people didn’t call me a boy. I’d falsely threaten to beat them up. I was way too much of a pacifist to ever do it, though. I guess I was kind of annoyed at people, but, then again, my physical presentation wasn’t something I was particularly aware of. I didn’t have that much of an issue with how people perceived me, because I didn’t get how people perceived me.”

Puberty complicated things. “When your body starts changing, it can be a weird time for anyone,” Skylar said. “But this definitely did not feel right.” It was like “walking around in a suit you couldn’t take off.” We were in the living room at his father’s house, on a cold, gray afternoon. Skylar was sitting cross-legged, wearing baggy athletic shorts, colorful socks, and a hoodie. He had floppy bangs, bright teeth, and dimples, and wore a diamond stud in his ear and a clutch of rubber wristbands. The testosterone had lowered his voice by an octave, and he spoke slowly; his speech had less pitch variation than the average girl’s, and his voice didn’t lilt upward at the end of a sentence. At one point, I asked him how tall he was, and he said, “Either five-six-and-a-half or five-seven. I’m spending a lot of time deciding whether I can legitimately go with five-seven.” While eating handfuls of Chex Mix, he described in detail his favorite shows, including “Doctor Who” and “Sherlock.” What I saw, having never met him before, was a kid who was boy-band cute and a little nerdy, in an unapologetic, proto-hipster way.

At thirteen, Skylar was browsing at Barnes & Noble and came across the young-adult novel “Parrotfish,” by Ellen Wittlinger, which, along with books like “Luna” and “I Am J,” is a touchstone for trans kids. “Parrotfish” is the story of Grady—born Angela—who realizes by page 9 that “inside the body of this strange, never-quite-right girl hid the soul of a typical, average ordinary boy.” Skylar had a flash of recognition; a few months later, after a bout of Internet research, he told Melissa and Chip that he was trans.

Skylar wanted to take testosterone right away—he wanted facial hair and a deeper voice and a more masculine frame. Melissa and Chip were receptive, but needed time to consider the ramifications. Melissa said, “To his credit, Skylar’s been amazingly patient with allowing Chip and me to internalize this and to get up to speed on it. You know, the whole idea of testosterone—there are permanent physiological changes that occur. So you want to be sure. And, while Skylar himself was sure, he was, after all, fourteen.”

Skylar started seeing a social worker in New Haven who works with transgender adolescents. Eventually, the social worker wrote a letter attesting to Skylar’s “gender dysphoria” but otherwise sound mental health. Endocrinologists require such a document before administering regular shots of a cross-gender hormone.

Weeks after Skylar started ninth grade, he announced his male identity by creating a Facebook page with his new gender status and name. The reaction of peers and administrators, he said, ranged from matter-of-fact to enthusiastic. It certainly didn’t hurt that Skylar, who projects quiet ambition, attends a public high school where superior students get respect from both teachers and classmates. There was some awkwardness about which bathroom he’d use: initially, he was given access to toilets in the principal’s office and the nurse’s office. But when Skylar started using the boys’ rest rooms nobody said anything, and that was that.

In a nearby town, Skylar found a support group for transgender teens. It had started in 2008, with just two kids, but by the time Skylar got involved there were sixty on the e-mail list and fifteen or so attending meetings regularly. There was a separate group for parents and, eventually, a group for siblings and one for kids under the age of twelve.

The group’s leader was Tony Ferraiolo, a burly, bearded fifty-year-old with a shaved head and Popeye forearms scrolled with tattoos. In his day job, at a company that makes industrial switches and sensors, he supervises thirty employees. Tony was born a girl and made the transition when he was forty-two.

The group, which met every three weeks, was composed primarily of F.T.M.s. Most of the kids had adopted new names and pronouns, but only a few were on hormones or had undergone surgery. Some had dealt with repeated hostility from their peers. Some had slept with girlfriends or boyfriends; others weren’t sure what their orientation would be once they became sexually active. Skylar said that he’d be dating boys. In the past, that trajectory would have been strikingly uncommon: a typical F.T.M. went from identifying as a lesbian to living as a straight man. But Skylar’s intended path—girl to gay guy—was less singular now. In any case, it was all a little gauzy and theoretical. Skylar considered his sexual orientation a more distant matter than his gender identity. “The whole sexuality thing never seemed like a huge deal,” he told me. “I never came out to anybody as gay. Sometimes I forget that coming out in terms of sexuality is still a big deal.” On another occasion, he said, “I’m in no way opposed to the idea of being with a girl or woman. But it’s a lot more likely it will be with a guy.”

In trans circles, it is a given that sexual orientation and gender identity are separate matters. It can be hard for some of us to imagine a sexuality that is not inextricably linked to our gender. But Tony often makes reference to a handy pictorial that was designed by trans activists. The Genderbread Person, shaped like a gingerbread man, has a cartoon heart denoting “sexual orientation”; a cartoon brain, for “gender identity”; a crotch area that represents “biological sex”; and a dotted line, surrounding the figure, that signifies “gender expression”—how you present yourself to the world, in behavior and dress.

Given that Skylar didn’t yet seem preoccupied with his sexuality, I felt almost boorish asking his parents how they felt his gender change might affect his romantic prospects. Would gay men want to date him? Melissa told me that she didn’t worry about it: “There was a point at the beginning of all this when we all thought, How are you going to find someone to love you? I think it’s going to be complicated, but people are going to love Skylar.” She was encouraged by the story of Layne, an F.T.M. who’d been in the group until he left for college. Layne had started presenting himself as a boy in high school, after “faking it” as a lesbian since middle school. (“I had the leather jacket, the boots, the faux-hawk.”) What he wanted, though, was to love girls as a boy. When he was accepted at the New School, in New York, he pressured his mother, who was reluctant, to let him start testosterone injections, saying that he wouldn’t go to college at all unless he could go as a boy. His mother relented. At freshman orientation, Layne met Mimi, an outgoing girl from Seattle, and felt an instant connection; they started dating and, as sophomores, were still together. “Young people today engage in really different kinds of relationships that I couldn’t have even imagined when I was sixteen,” Melissa said. Chip agreed: “They don’t immediately close off physical possibilities if something works for them emotionally.”

Many adults in Tony’s group—including Chip, Melissa, and her new husband, Roger—had become advocates for trans youth. But some parents wouldn’t come near the group, so a friend or a grandparent brought the kid. In some families, only one parent approved of a child’s gender switch, and the marriages had foundered. There was a girl in the group who had begun to transition, and whose parents then divorced, at which point the girl’s father declared that he was transgender, too.

Tony tells the parents, “You have to listen to your kids, affirm them, and then empower them to be who they want to be.” At the same time, he reminds the teen-agers that, overwhelming and fascinating as they find their gender identity, it’s not the only relevant thing about them. “Nobody walks around saying, ‘Hi, I’m a man,’ ” he told me. “So I say, ‘O.K., so you’re a dude. Good. Perfect. Love it. Now, what do you want to be when you grow up?’ ”

He also tries to help the kids understand their parents’ doubts and anxieties. “I say to the kids, ‘When you were born, your parents held you in their arms, and they had dreams for you. They didn’t say, “Oh, look at my beautiful daughter. Someday she’ll be my son!” ’ ”

This counsel of patience can be tough to get across. At one meeting, a girl in her mid-teens, who was starting the process of becoming male, mentioned feeling behind the curve. Many of the kids in the younger group, who were doing messy art projects in a room down the hall, were socially transitioning in elementary school. One of the meeting’s facilitators, Rachel—a pretty twenty-five-year-old M.T.F. who works as a computer programmer—spoke up. “I didn’t come out till I was eighteen, and it was O.K.,” she said. “Really.” Another kid said, “I didn’t come out till I was sixteen. It’s not necessarily a bad thing to come out late.” Clearly, “late” means something different to teen-agers.

At the beginning of group meetings, Tony and each of the kids share a “highlight and lowlight” of the past three weeks. When somebody announces that he or she has started taking cross-gender hormones, or is scheduled for surgery, the others clap. Last April, Skylar shared big news: nine days earlier, he’d had “top” surgery to remove his breasts and “masculinize” his chest. His endocrinologist and his therapist had recommended a plastic surgeon named Melissa Johnson, in Springfield, Massachusetts, who was willing to operate on kids under eighteen. After the kids stopped cheering for Skylar, they asked questions: Did he have a lot of pain when he woke up from the operation? What did the drains that were put in after surgery feel like? Was he totally psyched? Skylar said that all he needed was a few Vicodins on the day following the operation; after that, watching the first three seasons of “Buffy the Vampire Slayer” back to back was enough to distract him from the pain. He said that he was looking forward to going to the beach wearing just a rash guard with his trunks (he had to protect the incision site from the sun for a year while it healed); eventually, he’d go bare-chested. “Yeah, it’s a big deal when you don’t have to wear, like, a shirt over a shirt over a shirt anymore,” Tony said. Skylar wouldn’t be able to lift anything heavier than ten pounds for six weeks—he’d recruited friends at school to carry his backpack—but that wasn’t so bad.

Melissa told me that she had initially had some misgivings about Skylar’s desire to change gender. She recalled when Skylar asked to buy a binder—a nylon-and-Spandex vest worn under clothes to flatten breasts. “That, for me, was heartbreaking,” she said. “That’s when you realize that they don’t like their body. We, as women, grow up with a lot of expectations put on us about what we’re supposed to look like, and what we’re supposed to weigh and how big our breasts are supposed to be, and I’ve seen women mutilate themselves to try and meet that norm. And I really hate that idea.” But Melissa now considered her reaction “totally inappropriate.” She explained, “I was, like, ‘It makes me really sad that you can’t accept yourself, blah, blah, blah,’ without any real understanding of how misaligned his internal identity was with his external features.”

Last spring, when I asked Chip how he had felt when Skylar requested surgery, he said, “I try not to look backward. Personal experience, I guess, because if I did I’d be a mess. So I just tell myself, ‘Pull out the rearview mirror and throw it away,’ because all it’s going to do is stop me from getting where I want to go. With Skylar, in some ways I’ve done the same thing. This is what he wants. It’s not for me to want him to be a certain way.” Sometimes, deep in a conversation, Chip would mention having had doubts, but he sounded tentative when he tried to articulate what those doubts had been, especially if Skylar was in the room. In one such instance, he said, carefully, “We grow and evolve in such complex ways, and there still existed this lingering thought that maybe he’ll think, I shouldn’t have done this—I could have lived as a man without doing the surgery.”

One afternoon, Melissa and I picked up Skylar at the True Colors Conference, an annual event for gay and transgender youth, at the University of Connecticut, in Storrs. Skylar had co-taught a workshop on breast binding. (Don’t use Ace bandages, he warned—they can compress too tightly.) “How many kids were at your binding session?” Melissa asked him. “Like, fifty?”

“More like a hundred,” Skylar said from the back seat of the car.

“Wow, that’s amazing,” Melissa said.

Talking to Skylar and his friends drew me back to my years in graduate school, in the late eighties, when we talked a lot about “the social construction of gender” and frequently reminded one another that “sexuality has a history.” Skylar was reading the Epic of Gilgamesh for a class, and one day he told me, “This is so interesting to think about—my teacher had to sit us down and say, ‘Yes, Gilgamesh and Enkidu are lovers. No, they’re not necessarily gay. They just didn’t have a concept for that.’ ” Another time, he declared, “There aren’t two major categories of gender—every person has their own gender and will deal with it the way they deal with it.” Skylar wasn’t just engaging in intellectual play, however; he was putting theory into practice.

Certain as he seemed that he’d made the right decision, one thing that remained unresolved was the question of whether he would live as “Skylar, the trans guy” or “Skylar, the guy.” He clearly longed to be the latter—to start college as a boy without a complicated gender story, to not always be a spokesman for the trans experience. But he didn’t feel that “going stealth” was totally right or even desirable. In more intimate contexts, it wouldn’t be possible, anyway, since only the top half of his body had been reconstructed. But he also felt an obligation to keep talking about being trans: to journalists, to school administrators, to questioning youths at conferences. There’s a lot of pressure to be out these days—to own your identity and declare it, proudly, to the world.

Such thinking informed a choice that Skylar had made before having the mastectomy. There are two types of procedure: one of them leaves scars; the other does not, though he might need a second surgery. He got the one that leaves scars. “I ended up opting for the scars knowing they are forever—almost like a proof of what I’ve been through,” he said. “Why not have something to show for it?” It was the one decision that his mother tried to talk him out of.

A few months before I met Skylar and his family, I met a woman I’ll call Danielle, who lives in the San Francisco Bay Area. She, too, had a teen-age daughter who was becoming a son. (She requested a pseudonym to protect the privacy of her child, who declined to be interviewed.) Her daughter, who was about to start college at an art institute, had a history of depression. Danielle wasn’t convinced that gender confusion was the underlying cause, in part because her daughter, whom I’ll call Anna, hadn’t raised the subject until recently.

Anna was a dreamy girl who loved drawing, chafed at the strictures of school, and was beset by anxiety. In preschool, she’d climb into a tree house and perch there, refusing to come down. She hadn’t dated anyone seriously, but in high school she’d told her mother that she might like girls. Still, Danielle had not seen Anna as unusually masculine, or even androgynous. When Anna was in her last year at an alternative high school, she wrote Danielle a letter saying that she wanted to start taking testosterone and then have sex-reassignment surgery. Danielle took her to see a psychiatrist who specialized in gender issues. He prescribed antidepressants, but Anna refused to take them, saying that she knew too many kids who hadn’t been helped by them. The psychiatrist then advised Anna to take a year off before starting college, and to proceed immediately toward a surgical transition; that way, “her gender flags would be in order” when she matriculated. The idea worried Danielle: making art had always sustained Anna.

Danielle, who was divorced, had younger children at home, too, and they readily accepted the proposition that their sister was trans. Anna was now using a male name—I’ll call him Aidan—and his siblings quickly adopted it. Danielle’s ex-husband, with whom she had a trying relationship, didn’t balk at Aidan’s switch, either. While Danielle was at her college reunion, on the East Coast, he took Aidan to a clinic that administered testosterone. But Danielle, a lawyer who had studied literary theory in graduate school, told me that she found herself puzzling over Aidan’s desire to transition: “I feel like a lot of these kids, including my daughter, might be going through identity struggles, a lot of them are trying on roles.” We were having coffee at a pie shop in the Mission, at a long communal table. (At one point, the college student who’d been studying across from us politely interrupted to say that she, too, was about to transition to male.) Talking about Aidan, Danielle slipped back and forth between “she” and “he,” saying, “I’m still not convinced that it’s a good idea to give hormones and assume that, in most cases, it will solve all their problems. I know the clinics giving them out think they’re doing something wonderful and saving lives. But a lot of these kids are sad for a variety of reasons. Maybe the gender feelings are the underlying cause, maybe not.”

Danielle said that she had met many teen-agers who seemed to regard their bodies as endlessly modifiable, through piercings, or tattoos, or even workout regimens. She wondered if sexual orientation was beginning to seem boring as a form of identity; gay people were getting married, and perhaps seemed too settled.

“The kids who are edgy and funky and drawn to artsy things—these are conversations that are taking place in dorm rooms,” Danielle said. “There are tides of history that wash in, and when they wash out they leave some people stranded. The drug culture of the sixties was like that and the sexual culture of the eighties, with AIDS. I think this could be the next wave like that, and I don’t want my daughter to be a casualty.”

History is replete with examples of men and women who cross-dressed, and some of them, no doubt, would have remade their bodies, had the option existed. Before the twentieth century, it did not. In the nineteen-tens, German and Austrian scientists interested in the new field of endocrinology began attempting to change the sex of animals. Success with guinea pigs and rats encouraged doctors to respond positively to the human beings who yearned for gender metamorphosis. In 1931, in Berlin, a German waiter named Rudolf Richter had sex-reassignment surgery, becoming Dora. That same year, Einar Wegener, a Danish artist who had undergone several operations to become Lili Elbe, died after a failed procedure to create female reproductive organs. Her case was written up as a book, which appeared in English as “Man Into Woman: An Authentic Record of a Change of Sex.”

In America, doctors didn’t talk openly about the feasibility of sex-change operations until after the Second World War. In 1949, a psychiatrist named David O. Cauldwell began using the term “transsexual” to describe people so alienated from their biological sex that they wished to change it. The endocrinologist Harry Benjamin took the lead in promoting this idea, wresting gender discontent away from the psychoanalytic realm, where it was diagnosed as a disorder of sexual desire (curable through will power and talk therapy), and defining it as a problem of having been born in the wrong body (fixable through hormones and surgery). Benjamin helped establish a protocol requiring patients to receive a diagnosis of gender-identity disorder from a physician before taking hormones or undergoing surgery. Many transgender people have resented this kind of medical gatekeeping—and particularly the implication that they suffer from a mental illness. In 1973, homosexuality was removed from the Diagnostic and Statistical Manual of Mental Disorders, and some trans activists worked for years to get “gender identity disorder” expunged, too. Recently, they succeeded: in the next edition of the manual, which comes out in May, the term is replaced by “gender dysphoria”—a less pathologizing alternative that describes patients who report distress about their biological sex. (A diagnosis has its virtues—it allows some insurance plans to cover the transition process.)

The first American to go public about a gender reassignment was Christine Jorgensen, a glamorous twenty-six-year-old who, in 1952, had been obliged to travel to Copenhagen for the procedure. (When Jorgensen returned home to New York, the headline in the Daily News said, “EX-G.I. BECOMES BLONDE BEAUTY.”) In the sixties, American medical centers, beginning with Johns Hopkins, started to perform gender reassignments. From the outset, clinicians sought acceptance for the surgery by downplaying sexuality and emphasizing the “born in the wrong body” narrative. The patients most likely to be accepted for surgery were men who, like Jorgensen, seemed as if they could successfully live as straight women and not upset traditional roles all that much once they made it to the other side.

Fewer women sought operations, in part because the surgical techniques that were available lagged behind those for men. They still do. Many F.T.M.s get mastectomies and hysterectomies, but comparatively few have “bottom surgery.” M.T.F.s generally have labias and vaginas constructed, by a method in which the penis is inverted. Such surgery costs around fifteen thousand dollars. Creating a penis, a procedure known as phalloplasty, can cost more than a hundred thousand dollars. (Patients are usually responsible for most, if not all, of the cost.) Dr. Daniel Medalie, a plastic surgeon in Cleveland who does sex-reassignment operations, told me, “It’s just really difficult to make a fully functioning penis. It’s much easier to make a vagina—it’s easier to take away than to add.”

Estimates of the number of transgender people have never been particularly reliable and have almost certainly undercounted them. An often cited Swedish study, from 1967, included only people who had received treatment for gender-identity disorder, and showed one in thirty-seven thousand for biological males and one in a hundred and three thousand for biological females. But many people who consider themselves transgender either can’t afford treatment or don’t feel a need for it. Indeed, the term “transgender,” which became popular in the eighties, is an umbrella category that includes transsexuals, those who only take hormones, and people who defy their biological gender with clothes and makeup.

Trans people are increasingly choosing to place themselves somewhere between male and female: taking hormones for a while, then going off them; styling their appearance in gender-confounding ways but abstaining from medical procedures. Newer estimates for the prevalence of gender dysphoria are closer to one in ten thousand for both males and females.

In recent years, the most striking change for trans people is the possibility of switching gender at younger and younger ages. Some children have been encouraged to socially transition as early as preschool. And, according to some estimates, thousands of American adolescents are taking hormones that forestall puberty until they decide whether they want medical or surgical interventions to change their biological sex. Starting in the late seventies, doctors began prescribing these drugs for children who suffered from extremely precocious puberty. In 2000, a clinic in Holland began administering the drugs to kids who were struggling with their gender identity. The patients had to be at least twelve and had to have begun puberty; the drug put their sexual development on hold. At sixteen, patients could stop the hormones, allowing puberty to resume its course, or they could start a regimen of cross-gender hormones, whose effects are generally not reversible. Puberty suppressors gave patients the advantage of not fully developing certain features, such as breasts and a menstrual period, for F.T.M.s, and facial hair, a prominent Adam’s apple, and more masculine facial structure, for M.T.F.s. Puberty suppression and early surgery made for more convincing-looking men and women. The Dutch researchers Baudewijntje P. C. Kreukels and Peggy T. Cohen-Kettenis observed, “Early intervention not only seemed to lead to a better psychological outcome, but also to a physical appearance that made being accepted as a member of the new gender much easier, compared with those who began treatment in adulthood.”

The first American medical center to offer trans kids puberty blockers was Boston Children’s Hospital, in 2009. Clinics in several other cities, including Los Angeles, San Francisco, New York, and Seattle, soon followed. When I spoke recently with Norman Spack, an endocrinologist who runs the Boston program, he said that doctors in half a dozen more cities—among them Chicago, Cleveland, and Philadelphia—planned to adopt the puberty-suppressing protocol.

Doctors who see kids with gender-identity issues often attribute their increasing numbers to media coverage. Many of the stories on television are enthusiastic: the kids are adorable; the parents are so convinced. The story with the biggest reach has been that of Jazz, who was born a boy and socially transitioned while still a toddler. At six, he appeared on “20/20” as a mermaid-loving, lip-gloss-wearing girl. Jazz was subsequently interviewed on “60 Minutes” and starred in a documentary, “I Am Jazz: A Family in Transition,” that aired on the Oprah Winfrey Network. Jazz’s parents have started an advocacy organization, the TransKids Purple Rainbow Foundation. A YouTube clip in which Jazz explains that she has “a girl brain and a boy body” has been viewed more than a million times. Now, at twelve, Jazz has started a regimen of puberty-blocking hormones.

There are people who are sympathetic to families with kids like Jazz but worry about the rush to adopt the trans identity. They point out that long-term studies of young children with gender dysphoria have found that only about fifteen per cent continue to have this feeling as adolescents and adults. (And these studies, which relied on data from Dutch and Canadian research teams, looked only at children who were referred to a clinic for gender issues—presumably, many more kids experience gender dysphoria in some measure.) The long-term studies have also found that, when such kids grow up, they are significantly more likely to be gay or bisexual. In other words, many young kids claiming to be stuck in the wrong body may simply be trying to process their emerging homosexual desires.

Walter Meyer, a child psychiatrist and pediatric endocrinologist in Galveston, Texas, has prescribed puberty blockers and considers them worthwhile as a way to buy time for some kids. But, in an editorial that ran in Pediatrics last March, Meyer urged families not to jump to the conclusion that their fierce little tomboy of a daughter, or doll-loving son, must be transgender. “Many of the presentations in the public media . . . give the impression that a child with cross-gender behavior needs to change to the new gender or at least should be evaluated for such a change,” he wrote. “Very little information in the public domain talks about the normality of gender questioning and gender role exploration, and the rarity of an actual change.” When I called Meyer, he said, “What if people learn from the media and think, Hey, I have a five-year-old boy who wants to play with dolls, and I saw this program on TV last night. Now I see: my boy wants to be a girl! So I wanted to say in that article that, with kids, gender variance is an important issue, but it’s also a common issue. I’m saying to parents, ‘It may be hard to live with the ambiguity, but just watch and wait. Most of the time, they’re not going to want to change their gender.’ ”

Eli Coleman, a psychologist who heads the human-sexuality program at the University of Minnesota Medical School, chaired the committee that, in November, 2011, drafted the latest guidelines of the World Professional Association for Transgender Health, the leading organization of doctors and other health-care workers who assist trans patients. The committee endorsed the use of puberty blockers for some children, but Coleman told me that caution was warranted: “We still don’t know the subtle or potential long-term effects on brain function or bone development. Many people recognize it’s not a benign treatment.”

Alice Dreger, the bioethicist, said, of cross-gender hormones and surgery, “These are not trivial medical interventions. You’re taking away fertility, in most cases. And how do you really know who you are before you’re sexual? No child, with gender dysphoria or not, should have to decide who they are that early in life.” She continued, “I don’t mean to offend people who are truly transgender, but maybe a kid expresses a sense of being the opposite gender because cultural signals say girls don’t shoot arrows, or play rough, or wear boxers, or whatever. I’m concerned that we’re creating feedback loops in an attempt to be sympathetic. There was a child at my son’s preschool who, at the age of three, believed he was a train. Not that he liked trains—he was a train. None of us said, ‘Yes, you’re a train.’ We’d play along, but it was clear we were humoring him. After a couple of years, he decided that what he wanted to be was an engineer.”

Some parents worry that their children will be prematurely locked in place by the new emphasis on identifying young kids as trans. One mother in San Francisco, who writes about her family using the pseudonym Sarah Hoffman, told me about her son, “Sam,” a gentle boy who wears his blond hair very long. In preschool, he wore princess dresses—accompanied by a sword. He was now in the later years of elementary school, and had abandoned dresses. He liked Legos and Pokémon, loved opera, and hated sports; his friends were mostly science-nerd girls. He’d never had any trouble calling himself a boy. He was, in short, himself. But Hoffman and her husband—an architect and a children’s-book author who had himself been a fey little boy—felt some pressure to slot their son into the transgender category. Once, when Sam was being harassed by boys at school, the principal told them that Sam needed to choose one gender or the other, because kids could be mean. He could either jettison his pink Crocs and cut his hair or socially transition and come to school as a girl.

Hoffman ignored the principal’s advice. She told me, “Are we going to assume that every boy who doesn’t fit into the gender boxes is trans? Don’t push kids who aren’t going to go there.” Still, as Hoffman’s husband said, “It can be difficult for people to accept a child who is in a place of ambiguity.” A kid with a nameable syndrome who requires a set of specific accommodations at school (recognition of a new name, the right to use the bathroom and locker room he or she wants to) is, in some ways, easier to present to the world than a child who occupies a confusing middle ground.

Many other parents believe that they will be saving their children pain in the future if they sort out their gender confusion now. This impulse is ratified by many transgender adults, who say they wish they could have skipped going through puberty in the wrong sex.

At a conference in Philadelphia devoted to transgender health, I attended a panel of parents discussing their gender-nonconforming kids. A man in the audience said that he had a son “who, at two, was very clear in teaching us how he wanted to dress and how he wanted to be in the world. Now he’s almost three and I’m trying to let this be a wonderful gender-fluid period, but I wonder if I’m holding him back. Like, should I be asking, ‘Do you want to be called he or she?’ ” A woman in the audience confessed to her own desire for closure: “We want to know—are you trans or not?”

Last summer, I met Catherine Tuerk, a nurse who started a support program for gender-nonconforming kids in Washington, D.C. She showed me a photograph of herself as a child of nine or ten. In the picture, she looks exactly like a boy. Her hair is cut in a ducktail—she recalled dashing into the barbershop in her little Pennsylvania town and asking for a crewcut, and being offered a compromise. Some of her fondest memories of her nineteen-fifties childhood were of racing around town on her bike in only jeans, a cowboy belt, and high-tops—“A shirt would have ruined everything,” Tuerk said. She called this period her “glory days,” and sometimes wonders why some of the girls she’s met through her work today don’t have more fun “liking to be boys,” as she did. It was a paradox: she grew up in a time when gender roles for adults were much more straitened; yet, as a young girl, her ambit had seemed wider, partly because there was less awareness of what her behavior might augur for adulthood. As a heterosexual who became a happily married mother, she acknowledges that her memories may remain lovely for her because she was untroubled by her gender identity. “But who knows what would happen if I were growing up like that now?” she said. “I’d be Carl, I guess.”

It is common today to speak of the plasticity of the adolescent brain. A recent Health and Human Services Department memo cited research suggesting that in adolescents the brain is still evolving “in its ability to organize, regulate impulses, and weigh risks and rewards.” Because brain circuitry is still falling into place, it can be difficult for adolescents “to think critically before making choices,” and they’re more driven by impulse. In the legal realm, this research has provided a scientific anchor for the idea that juvenile criminals should be treated with leniency; in the domestic realm, it has contributed to parental hovering and an acceptance of delayed adulthood. Trans politics, however, is moving in the opposite direction, toward allowing adolescents to make profound, unalterable decisions earlier.

The World Professional Association for Transgender Health, in its latest guidelines, still recommends that Americans wait until eighteen for genital surgery, but says that chest surgery may be done earlier. There is some scientific grounding for this position: researchers have found that, if a young child’s gender dysphoria persists past the onset of puberty, as Skylar’s did, he or she is likely to retain those feelings into adulthood.

Nevertheless, some surgeons who do gender reassignment are skeptical of early surgery. Charles Garramone, a plastic surgeon in the Fort Lauderdale area, will not perform sex-reassignment operations on minors, because, he says, “patients need to have a mature outlook in terms of being able to really understand the irreversibility of this surgery.” In addition, Garramone thinks that the skeletal structure underlying the chest of a sixteen-year-old may change enough over time so that a second surgery will be required. Kathy Rumer, a plastic surgeon outside of Philadelphia who has a large transgender practice, also declines to perform reassignment surgery on minors. “I have had parents plead with me,” she says. “And I can feel for them. But I don’t want someone coming back to me when they are twenty-five saying, ‘I didn’t really want this. It was my parents.’ Adolescents are really in flux. I wouldn’t want to make a permanent change based on that stage of life, which can be difficult, no matter what you’re going through.”

Some advocates, meanwhile, want to broaden the range of sex-reassignment surgeries available to young patients. A psychologist who sees many trans clients in Northern California told me that he wants the World Professional Association to consider loosening its guidelines for youth even further. “Here’s an example,” the psychologist, who asked to remain anonymous, said. “I see a child, a trans girl, who came out at three and is now seven. She’s clearly a female. There’s no ambiguity or inconsistency. She goes to school and presents as a girl. Absolutely the only reason to hinder it would be that you need to wait for her body to get bigger, so there is enough flesh to make a new vagina.” The psychologist used to focus on adult patients, but now he sees little kids and teen-agers as well. A strong advocate of puberty blockers, he said that cross-gender hormones should be administered to kids before they’re sixteen, adding, “I’m assuming that, down the road, we’ll be looking at ways to get surgery earlier, too.”

A sex change is a dramatic experience at any time, but for an adolescent it can take on a particularly heightened cast. This is evident in the many YouTube videos in which teen-agers chronicle their transitions. The videos sometimes display a preening preoccupation with minute physical changes (a sprinkling of facial hair, a shadow of cleavage) and an eye-rolling impatience with adults who exhibit any hesitation or befuddlement about the kids’ desire to change gender. A good number are slide shows, accompanied by pop ballads, that start with baby pictures. At the same time, many of the videos offer detailed practical advice and thoughtful, diaristic explorations of what it’s like to be trans. Some of the more interesting ones focus on the ethics and the logistics of “passing.” Generally, the earlier kids start on cross-gender hormones—especially if they’ve taken puberty blockers—the easier it is for them to go stealth, and convincingly adopt a new gender without disclosing their trans status. But even people who start their transitions at a later age have to decide how to present their history. Some kids in the midst of transitioning speak about their confusion or guilt over passing. In one clip, Natalie, an M.T.F. with chunky glasses and long dark hair, confesses, “The more I feel like I pass as a genetic woman, the more it bothers me, because I am not a biological woman.”

Some kids post videos of themselves with their boyfriends or girlfriends, often proudly emphasizing that these partners are “cisgendered”—a term for people whose biological sex and gender identity match up. Some speak frankly about the dilemmas of dating. One video features a college-age F.T.M., with sideburns and a baseball cap, complaining that dating gets so physical so fast these days that he’s forced into explanations about his genitalia before he’s gotten to know a girl. A handsome Dutch F.T.M. says that he’s decided not to reveal his trans status on Internet dating sites, because it’s better when girls “meet you and see that there’s absolutely almost no difference between you and other guys except for one really shallow kind of thing.”

In a series of videos called “Not Trans Enough,” young F.T.M.s talk about feeling rejected or judged by other trans people for failing to act more conventionally masculine. Their shortcomings: “I don’t work out”; “I don’t play Xbox”; “I have more on my mind than just sex”; “I’d rather watch Disney over action movies”; “I doodle hearts in class.” Even worse, they didn’t socially transition as toddlers—the new badge of authenticity. Of course, adopting a new identity doesn’t fully explain you, and it doesn’t mean that the community you’ve embraced will embrace you back. If you’re young enough, such realizations can seem momentous and unmooring.

Even for kids who are not “trans enough,” the dream of finding the perfect niche endures. At a workshop called “Binary Defiance,” at the True Colors Conference, the facilitator wrote specialized gender labels on the blackboard so fast that I practically sprained my wrist writing them down: “non-binary, gender queer, bigender, trigender, agender, intergender, pangender, neutrois, 3rd gender, androgyne, two-spirit, self-coined, genderfluid.” These ever-narrower labels are meant to be liberating, offering people their own customized categories, but they often seem predicated on stereotypical notions about men and women. One can, after all, be a man who doesn’t like to work out or play Xbox. Or a woman who doesn’t feel especially feminine. Skylar, at one point, told me that he sometimes longed for a time when we would be able to dispense with labels altogether.

I kept in touch with Danielle, the woman from the Bay Area. Aidan had started art school on time, rejecting the advice of the psychiatrist who had advised delaying college for a year. As far as Danielle knew, Aidan was also giving himself testosterone, though now that he had turned eighteen she had less direct information about his medical care. In the fall of his freshman year, he had a medical crisis—heart irregularities and a spike in blood pressure—which a doctor thought had been caused, or exacerbated, by the testosterone. He wore a binder, which gave him a more masculine profile, and people now assumed that he was male when they met him. But Aidan wasn’t talking as much about surgery, and he seemed happier. Danielle felt that Aidan’s talents were appreciated in art school, and that having a creative outlet “took the focus off his body for a while.”

Lately, Aidan had been making art installations that were abstract, funny, and generally unconcerned with gender. One of them had been shown in a commercial gallery. Danielle thought that perhaps he was shifting “from ‘The solution to pain is becoming a man’ to ‘The solution is becoming an artist.’ ” But she knew that it was ultimately Aidan’s decision.

Skylar is now in the middle of his senior year. He was accepted at the University of Chicago, and offered an academic scholarship. In January, at a dinner with Chip, Melissa, and her husband, Roger, Skylar seemed more confident than when I first met him—relaxed, jokey, less prone to slouch. He’d been refining his sense of style, too. With a blue plaid shirt, a tweed vest, hiking boots, and freshly cut hair, he could have been one of the guys grouped around a vintage turntable in an Urban Outfitters catalogue. When I asked him if he felt like a pioneer, he was embarrassed by the term. But he noted that, since we’d talked, four other people at his school had come out as trans.

The family began discussing what Skylar’s life might be like after college. Melissa could vividly imagine only one potential constraint for Skylar: international travel. She spoke of some transgender kids in the support group who had gone to China; they were “very concerned about documentation and what happens if someone gets stopped.”

Skylar said, “I do think about situations I could get into—like what if I tell the wrong person.”

“I’m sorry you have to worry about that,” Roger said.

In the fall, Skylar’s high school had announced that it would be electing a Homecoming King and Queen for the first time. After some students pointed out that, as Skylar put it, “not everybody would fit either label,” the school adopted the term “Homecoming Court.” Skylar decided to run for the court with his friend Julia, who considers herself “genderqueer.” They won. At the Homecoming Dance, Skylar wore a natty gray vest and a tie, and Julia wore aviator sunglasses and a tight black tank dress. They were crowned with matching gold plastic headpieces.

The next day, Skylar attended a conference on youth leadership. He gave a speech in which he recounted being picked for Homecoming Court, even though he and Julia are “ridiculously, openly queer.” He wasn’t bragging, he said—it just made him “really happy that that was possible at my school.” Skylar was amused, and flattered, when a girl from another school came up to him afterward to say that she and her friends thought he was cute. For a while that afternoon, there were several girls following him around, giggling and smiling over their new crush. ♦

Margaret Talbot is a staff writer and the author of “The Entertainer.”